HospitalInspections.org

Based on interview and record review the facility failed to provide care in a safe setting when the hospital staff failed to follow current standards of practice for infection control.

Findings were:

In review of an email sent to PACU (Post-anesthesia Care Unit) staff, Subject: safety coach update, Sent: Wednesday, March 13, 2019 2:33 PM stated, "...2. Because of the recent patient blood exposure while using a dirty yaunker we are changing the way we do our suction set up. From now on you should not attach the Yaunker to the tubing until you actually need it. Since the packaging says "do not use if package is open or damaged" it was decided that not opening would be best practice. What I have started doing is just attaching it when I know I am getting a patient that will likely need suctioning (T + A, palatoplasty, dental, etc). If it is opened but doesn't get used then go ahead and throw it out and put out a new unopened one."

In an interview with an orienting staff RN on 6/6/19 at 12:10 PM she stated, "We grabbed the suction tubing and suctioned (patient last name used here). (Staff #4) pulled over the tubing for me to look at and asked if I had seen this before, a spot of blood on the Yankauer about the size of my nail. Since this incident we have changed the way we do things. We use to have everything ready to go, so the Yankauer package was opened and Yankauer connected to the tubing and Yankauer put back in its original packaging. Now we don't open any packages until the patient is there and we need to suction the patient. We talked to my supervisor and talked to the patients' family after the surgery and explained what happened. The patient had lab work done."

In an interview with PACU RN on 6/6/19 she stated, "(patients first name used here) had a tonsillectomy. In recovery I reached for my suction pulled it out of the sleeve and suctioned him. When I was putting the Yankauer back into the sleeve I noticed a small amount of dried blood on the Yankauer. When I checked everything that morning nothing was out of the ordinary. The nurse or the nurse's aides can set up the room. We make sure that out Ambu bag, suction, oxygen source and supplies are there."

Review of Summary of Investigation Follow Up, completed on 3/26/19 stated in part, " ...Investigation summary: PACU (Post-anesthesia Care Unit) RN suctioned patient with yaunker [sic] and noticed bloody drainage when placing the yaunker back in the packaging. Staff #8, #9, #10, #11, and risk management all notified. Pt's family notified in PACU. Orders placed for labs to be drawn and follow up with ID (Infectious Disease). Process change in PACU to not connect yaunkers to suction tubing until ready to use on patient ..."

The above findings were confirmed with the facility Director of Quality.